PRINTER'S NO. 151
No. 155 Session of 1997
INTRODUCED BY ULIANA, JUBELIRER, WAGNER, O'PAKE, AFFLERBACH,
KITCHEN, MELLOW, BELAN, HELFRICK, PUNT, GERLACH, SCHWARTZ,
WOZNIAK, MURPHY, TARTAGLIONE AND KASUNIC, JANUARY 21, 1997
REFERRED TO BANKING AND INSURANCE, JANUARY 21, 1997
AN ACT
1 Requiring all health insurance carriers that provide for
2 coverage for mastectomies also include coverage for
3 prosthetic devices and reconstructive surgery.
4 The General Assembly of the Commonwealth of Pennsylvania
5 hereby enacts as follows:
6 Section 1. Short title.
7 This act shall be known and may be cited as the Breast Cancer
8 Reconstructive Surgery Insurance Coverage Act.
9 Section 2. Declaration of policy.
10 The General Assembly finds and declares as follows:
11 (1) Breast cancer is the most common cancer in American
12 women, afflicting 182,000 women per year, striking one out of
13 9 and killing 46,000 a year. Coping with this disease is a
14 medical and emotional struggle since it carries with it the
15 fear of disfigurement in a society that places great value on
16 physical appearance.
17 (2) Some insurance carriers deny coverage for breast
18 reconstruction, considering the procedure not medically
1 necessary. Most insurance companies will not cover procedures
2 on the opposite breast to provide symmetry for the
3 reconstruction, but do cover reconstruction of other body
4 parts, which is discriminatory.
5 Section 3. Definitions.
6 The following words and phrases when used in this act shall
7 have the meanings given to them in this section unless the
8 context clearly indicates otherwise:
9 "Health insurance policy." Any individual or group health,
10 sickness or accident policy or subscriber contract or
11 certificate issued by an entity subject to any one of the
12 following:
13 (1) The act of May 17, 1921 (P.L.682, No.284), known as
14 The Insurance Company Law of 1921.
15 (2) The act of December 29, 1972 (P.L.1701, No.364),
16 known as the Health Maintenance Organization Act.
17 (3) The act of May 18, 1976 (P.L.123, No.54), known as
18 the Individual Accident and Sickness Insurance Minimum
19 Standards Act.
20 (4) The act of December 14, 1992 (P.L.835, No.134),
21 known as the Fraternal Benefit Societies Code.
22 (5) 40 Pa.C.S. Ch. 61 (relating to hospital plan
23 corporations) or 63 (relating to professional health services
24 plan corporations).
25 (6) Medical assistance.
26 The term does not include accident only, fixed indemnity,
27 limited benefit, credit, dental, vision, specified disease,
28 Medicare supplement, long-term care or disability income,
29 workers' compensation, or automobile medical payment insurance
30 policies.
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1 "Mastectomy." The removal of all or part of the breast for
2 medically necessary reasons, as determined by a licensed
3 physician.
4 "Prosthetic devices." The use of initial and subsequent
5 artificial devices to replace the removed breast or portions
6 thereof, pursuant to an order of the patient's physician.
7 "Reconstructive surgery." A surgical procedure performed
8 following a mastectomy on one breast or both breasts, as
9 determined by a licensed physician, to restore and achieve
10 symmetry between the two breasts. This term shall include, but
11 is not limited to, augmentation mammoplasty, reduction
12 mammoplasty and mastopexy.
13 "Symmetry between breasts." Equality in size of the
14 nondiseased breast with the diseased breast after definitive
15 reconstructive surgery on the diseased breast has been
16 performed.
17 Section 4. Mandated coverage for reconstructive surgery
18 incident to mastectomy.
19 (a) Included coverage.--Every health care policy which is
20 delivered, issued for delivery, renewed, extended or modified in
21 this Commonwealth by a health care insurer which provides
22 coverage for the surgical procedure known as mastectomy shall
23 also include coverage for prosthetic devices and reconstructive
24 surgery incident to the mastectomy, which shall include
25 reconstructive surgery to restore and achieve symmetry of the
26 opposite breast after mastectomy.
27 (b) Deductible and coinsurance.--Coverage for prosthetic
28 devices and reconstructive surgery shall be subject to the
29 deductible and coinsurance conditions applied to the mastectomy
30 and all other terms and conditions applicable to other benefits.
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1 (c) Limitations.--In the event that a mastectomy is
2 performed and there is no evidence of malignancy, the coverage
3 for prosthetic devices inserted during reconstructive surgery
4 and reconstructive surgery in this section may be limited to
5 such surgical procedures performed within two years of the date
6 of the mastectomy.
7 Section 5. Applicability.
8 This act shall apply to all insurance policies, subscriber
9 contracts and group insurance certificates issued under any
10 group master policy delivered or issued for delivery on or after
11 the effective date of this act. This act shall also apply to all
12 renewals of contracts on any renewal date which is on or after
13 the effective date of this act.
14 Section 6. Effective date.
15 This act shall take effect in 60 days.
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